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non slithering country

Mohammad Reshad Chumroo chumrooreshad at doctors.org.uk
Sun Apr 1 21:15:19 BST 2012


I agree. I think the only reptile in New Zealand is the 
Tuatara and they are on the brink of extinction.

Reshad

On Sun, 01 Apr 2012 19:30:32 +0100
  trauma-list-request at trauma.org wrote:
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> 
> Today's Topics:
> 
>   1. Re: non slithering country  (Marcin & Ania)
>   2. Re: Fasciotomy after viper bites (Dr Timothy 
>Hardcastle)
>   3. Re: trauma-list Digest, Vol 105, Issue 11 (daniel 
>simon)
>   4. ICU to ICU transfers: what is your policy? (Caesar 
>Ursic)
>   5. Re: non slithering country (Caesar Ursic)
>   6. Re: ICU to ICU transfers: what is your policy?
>      (Dr Timothy Hardcastle)
>   7. Re: ICU to ICU transfers: what is your policy? 
>(Gross, Ronald)
>   8. Re: ICU to ICU transfers: what is your policy? 
>(Robert Smith)
>   9. Re: ICU to ICU transfers: what is your policy? 
>(Caesar Ursic)
>  10. RE: ICU to ICU transfers: what is your policy? 
>(McSwain, Norman E)
>  11. RE: ICU to ICU transfers: what is your policy? 
>(McSwain, Norman E)
>  12. Re: ICU to ICU transfers: what is your policy? (K 
>Mattox)
>  13. Re: ICU to ICU transfers: what is your policy? (K 
>Mattox)
>  14. Re: ICU to ICU transfers: what is your policy? 
>(Gross, Ronald)
>  15. Re: ICU to ICU transfers: what is your policy? 
>(Caesar Ursic)
> 
> 
> ----------------------------------------------------------------------
> 
> Message: 1
> Date: Sat, 24 Mar 2012 20:38:58 +1300
>From: "Marcin & Ania" <Zawisza at xtra.co.nz>
> Subject: Re: non slithering country 
> To: trauma-list at trauma.org
> Message-ID: <op.wbnzi8lk8pjabq at dell.lan>
> Content-Type: text/plain; charset=iso-8859-15; 
>format=flowed;
> 	delsp=yes
> 
> In answer to your question Brian- New Zealand is your 
>best bet :-)
> 
> Martin
> 
> 
> Not to change the subject, but as someone who loves 
>tropical and
> semi-tropical weather but is absolutely TERRIFIED (i can 
>BARELY stand being
> in the reptile house at the zoo, i probably need 
>professional help, huh?
>  of snakes, is there anywhere on Earth I can get the 
>great weather
> combined with a lack of the slithering devils?
> Bryan
> 
> 
> 
> ------------------------------
> 
> Message: 2
> Date: Sat, 24 Mar 2012 18:52:47 +0200 (SAST)
>From: "Dr Timothy Hardcastle" 
><dr.tchardcastle at absamail.co.za>
> Subject: Re: Fasciotomy after viper bites
> To: "Trauma-List \[TRAUMA.ORG\]" 
><trauma-list at trauma.org>
> Message-ID:
> 	<10967.41.242.231.132.1332607967.squirrel at aiamail.lantic.net>
> Content-Type: text/plain;charset=iso-8859-1
> 
> Sahaj
> 
> Never seen that - means I've probably not seen enough 
>snake-bites. :)
> The "allergy" is a Type 3 reaction to the antivenin if 
>used - hence why
> you only give on indication.
> 
> Tim
>> So I have a sort of unrelated snake bite question.
>>
>> What is the rate of anaphylaxis from snake bites?
>>
>> How can one get anaphylaxis to the venom if they haven't 
>>been previously
>> bit?  Are there proteins in the venom that are also 
>>present in other, more
>> common, types of venom?  Is that what the reaction is 
>>to?
>>
>> I guess that's more than one question, huh?
>>
>> Thanks,
>>
>> Sahaj Khalsa
>> NREMT-P
>>
>> On Fri, Mar 23, 2012 at 12:30 PM, Bryan Boling
>> <bryanboling at gmail.com>wrote:
>>
>>> On Fri, Mar 23, 2012 at 1:36 PM, Sanjay Gupta
>>> <sanjaygupta99_91 at yahoo.com
>>> >wrote:
>>>
>>> > In US, in the state of West Virginia
>>>
>>>
>>> That says it all right there...
>>>
>>> :-)
>>>
>>>
>>>
>>> > there is a snake pit day when young brave men and 
>>>women enter into a
>>> pit
>>> > full of poisonous snakes!!
>>> >
>>> >
>>> > Sanjay Gupta
>>> >
>>> > From: T. Al West <talwest at mac.com>
>>> > To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
>>> > Sent: Friday, March 23, 2012 8:27 AM
>>> > Subject: Re: Fasciotomy after viper bites
>>> >
>>> > My favorite snake stupidity story involves a diabetic 
>>>with advance
>>> > retinopathy who kept a live Western diamondback 
>>>rattlesnake as a "pet"
>>> in a
>>> > glass herpetarium at home.
>>> >
>>> > Most common pre-mortem "last words" in Texas-- "Hey, 
>>>y'all, watch
>>> this!"
>>> >
>>> > I was born and raised in Texas, so I can make fun--the 
>>>rest of you
>>> better
>>> > watch it!
>>> >
>>> > Al
>>> >
>>> > On Mar 22, 2012, at 9:14 PM, Ian Seppelt wrote:
>>> >
>>> > > Thinking of all the snakebites I have treated:
>>> > >
>>> > > - the vast majority involve sheer stupidity (amateur 
>>>herpetologists
>>> > beyond their skill levels, or individuals with 
>>>impaired sense due to
>>> > various substances "let's poke this snake and see what 
>>>happens" etc).
>>> > > - professional herpetologists hardly ever get bitten
>>> > > - the occasional person gets bitten in remote areas 
>>>eg down a canyon
>>> > (bad luck)
>>> > > - children touch things they shouldn't
>>> > > - I have had one patient who was a middle aged woman 
>>>just minding
>>> her
>>> > own business gardening ...
>>> > >
>>> > > Snakes are common but are more scared of us than we 
>>>are of them. I
>>> have
>>> > snakes in my backyard and occasionally around the 
>>>house. I teach my
>>> kids
>>> to
>>> > be sensible, not put hands anywhere dark without 
>>>looking first -
>>> especially
>>> > careful of the woodpile and behind the shed (where I 
>>>know a black
>>> snake
>>> > lives), and if they do see a snake 'look don't touch, 
>>>walk away don't
>>> > panic'. No point trying to get rid of them - if you 
>>>have a nice snake
>>> > habitat then another will move in just as soon as one 
>>>has been
>>> relocated.
>>> > Treat them with a bit of respect and they are fine.
>>> > >
>>> > > I also have a breeding colony of redback spiders in 
>>>the shed if
>>> anyone
>>> > wants some, and some funnelwebs up the back near the 
>>>arena ......
>>> > >
>>> > > Ian Seppelt,
>>> > > in a semi-rural area in the west of Sydney.
>>> > >
>>> > > On 23/03/12 11:43 AM, John Holmes wrote:
>>> > >> Australia !  You really have to either grossly 
>>>stupid or unlucky to
>>> get
>>> > bitten.  It's just not an issue unless you're deep in 
>>>the outback
>>> looking
>>> > for trouble.
>>> > >>
>>> > >> :)
>>> > >>
>>> > >> John
>>> > >>
>>> > >> Dr John L Holmes
>>> > >> Senior Staff Specialist
>>> > >> Department Emergency Medicine
>>> > >> Caloundra Hospital
>>> > >> Queensland  4551
>>> > >>
>>> > >> Australia
>>> > >>
>>> > >>> Date: Thu, 22 Mar 2012 20:38:10 -0400
>>> > >>> Subject: Re: Fasciotomy after viper bites
>>> > >>> From: bryanboling at gmail.com
>>> > >>> To: trauma-list at trauma.org
>>> > >>>
>>> > >>> Not to change the subject, but as someone who 
>>>loves tropical and
>>> > >>> semi-tropical weather but is absolutely TERRIFIED 
>>>(i can BARELY
>>> stand
>>> > being
>>> > >>> in the reptile house at the zoo, i probably need 
>>>professional
>>> help,
>>> > huh?
>>> > >>> :-) of snakes, is there anywhere on Earth I can 
>>>get the great
>>> weather
>>> > >>> combined with a lack of the slithering devils? :-)
>>> > >>> Bryan
>>> > >>>
>>> > >>> On Thursday, March 22, 2012, John
>>> Holmes<docjohnholmes at hotmail.com>
>>> > wrote:
>>> > >>>> Totally agree with Ian; the treatment of snake 
>>>envenoming needs
>>> to
>>> be
>>> > >>> specific to the different snakes in different 
>>>continents.
>>> > >>>> Here in Australia our elapids' toxins comprise 
>>>varying
>>> combinations
>>> of
>>> > >>> neurotoxins, myotoxins and most significantly 
>>>haemolysins and
>>> > >>> coagulotoxins.  Local tissue necrosis is only a 
>>>minor component of
>>> > >>> Australian snake venoming.
>>> > >>>> There has also been a long development of 
>>>antivenom development
>>> in
>>> > this
>>> > >>> country and current antivenoms are (relatively) 
>>>antigenically
>>> "clean".
>>> > >>>  Interestingly new evidence points to much lower 
>>>dosage of
>>> antivenom
>>> > >>> whereas a few years ago much larger doses were 
>>>being advocated.
>>> > Despite
>>> > >>> this, there is no doubt that in severely 
>>>coagulopathic snake bite
>>> > >>> envenomings, the use of appropriate amounts of 
>>>antivenom has saved
>>> > >>> countless lives in this country.
>>> > >>>> John
>>> > >>>>
>>> > >>>>
>>> > >>>> Dr John L Holmes
>>> > >>>> Senior Staff Specialist
>>> > >>>> Department Emergency Medicine
>>> > >>>> Caloundra Hospital
>>> > >>>> Queensland  4551
>>> > >>>>
>>> > >>>> Australia
>>> > >>>>
>>> > >>>>> Subject: Re: Fasciotomy after viper bites
>>> > >>>>> From: seppelt at med.usyd.edu.au
>>> > >>>>> Date: Fri, 23 Mar 2012 07:15:17 +1100
>>> > >>>>> CC: trauma-list at trauma.org
>>> > >>>>> To: trauma-list at trauma.org
>>> > >>>>>
>>> > >>>>> This advice may well be perfectly correct for 
>>>many (most?)
>>> snakes
>>> > around
>>> > >>> the world but completely wrong for Australian 
>>>elapids (which
>>> include
>>> > many
>>> > >>> of the world's most venomous).
>>> > >>>>> Not every snake bite needs antivenom but severe 
>>>envenomation
>>> > certainly
>>> > >>> does and it is very dangerous advice to suggest 
>>>avoiding antivenom
>>> and
>>> > >>> treat severe coagulopathy with just coagulation 
>>>factor
>>> replacement.
>>> > >>>>> Bottom line is that snakes are not the same 
>>>around the world.
>>> You
>>> > must
>>> > >>> know the right treatment for snakebites where you 
>>>work but do not
>>> > assume
>>> > >>> exotic snakes from elsewhere in the world are the 
>>>same - seek
>>> expert
>>> > advice.
>>> > >>>>> Ian Seppelt
>>> > >>>>>
>>> > >>>>> On 23/03/2012, at 4:10 AM, Kenneth 
>>>Mattox<kmattox at aol.com>
>>> wrote:
>>> > >>>>>
>>> > >>>>>> At the BTGH, over the years, we have had our 
>>>share of poisonous
>>> > snake
>>> > >>> bites, from snakes indigenous to the area (to 
>>>include water
>>> moccasin
>>> > >>> snakes, copperhead snakes, rattlesnakes, and coral 
>>>snakes), to
>>> those
>>> > owned
>>> > >>> by snake handlers, to include all sorts of vipers 
>>>from Africa,
>>> India,
>>> > and
>>> > >>> Australia (including cobras, etc), to those used 
>>>and housed by
>>> > companies
>>> > >>> who own all varieties of poisonous snake in order 
>>>to make
>>> > pharmaceuticals,
>>> > >>> to those housed in the local zoo snake house and 
>>>have
>>> occassionally
>>> > bitten
>>> > >>> the snake handlers.
>>> > >>>>>> We have chosen to evaluate each and every snake 
>>>bite separately
>>> and
>>> > >>> have NOT been fans of antivenin for any snake 
>>>bite, including
>>> coral
>>> and
>>> > >>> cobra bites.    We DO wide and complete 
>>>fasciotomies for  ANY
>>> > compartent
>>> > >>> syndrome, regardless of the cause IF we 
>>>demonstrate increased
>>> > compartment
>>> > >>> pressures.    During the past 30+ years we have 
>>>probably done no
>>> more
>>> > than
>>> > >>> 3-5 fasciotomies in patients with snake bites, and 
>>>those were
>>> > rattlesnake
>>> > >>> bites in the forearm or hand.
>>> > >>>>>> Should a snake bite victim develope respiratory 
>>>insufficiency
>>> they
>>> > are
>>> > >>> admitted to the ICU and ventilated for a day  or 
>>>so..    If they
>>> > develop a
>>> > >>> coagulopathy, we treat the deficit specifically.
>>> > >>>>>> For patients who have received antivenin in 
>>>OTHER hospitals we
>>> see
>>> > >>> high rates of serum sickness several weeks later. 
>>>   We have had
>>> ONE
>>> > digit
>>> > >>> loss and no extremity losses .    The digit loss 
>>>was a necrotic
>>> finger
>>> > >>> which was necrotic and many hours post bite when 
>>>the patient came
>>> in,
>>> > and
>>> > >>> it too was a rattlesnake bite .
>>> > >>>>>> K Mattox
>>> > >>>>>>
>>> > >>>>>>
>>> > >>>>>> -----Original Message-----
>>> > >>>>>> From: Pradeep 
>>>Navsaria<Pradeep.Navsaria at uct.ac.za>
>>> > >>>>>> To: trauma-list<trauma-list at trauma.org>
>>> > >>>>>> Sent: Thu, Mar 22, 2012 4:26 am
>>> > >>>>>> Subject: Re: Fasciotomy after viper bites
>>> > >>>>>>
>>> > >>>>>>
>>> > >>>>>> The treatment of a compartment syndrome, 
>>>irrespective of cause,
>>> is a
>>> > >>>>>> fasciotomy!
>>> > >>>>>>
>>> > >>>>>> Pradeep
>>> > >>>>>>
>>> > >>>>>>
>>> > >>>>>> Trauma Center
>>> > >>>>>> Cape Town
>>> > >>>>>>>>> Miranda Voss<mvossak at yahoo.co.uk> 
>>> 2012/03/22 10:56 AM>>>
>>> > >>>>>> Dear List Members,
>>> > >>>>>>
>>> > >>>>>> It is still pretty much standard teaching in 
>>>South Africa that
>>> if
>>> > you
>>> > >>>>>> suspect a compartment syndrome after a 
>>>cytotoxic snake bite,
>>> you
>>> > should
>>> > >>>>>> do a fasciotomy. I see that there are now 
>>>recommendations -
>>> > >>> particularly
>>> > >>>>>> from WHO - that fasciotomy in cytotoxic snake 
>>>bite should be
>>> > avoided if
>>> > >>>>>> at all possible. I believe the concern is 
>>>bleeding from
>>> associated
>>> > >>>>>> coagulopathy, but I am uncomfortable with this. 
>>>Would anybody
>>> here
>>> > not
>>> > >>>>>> do a fasciotomy for a cytotoxic snake bite with 
>>>limb swelling
>>> and
>>> > pain
>>> > >>>>>> on passive stretch of the flexor muscles? We 
>>>have never
>>> measured
>>> > >>>>>> compartment pressures because we teach that a 
>>>suspected
>>> compartment
>>> > >>>>>> syndrome should be treated with fasciotomy. 
>>>Does anybody else
>>> have a
>>> > >>>>>> view? I have seen the pictures on the WHO 
>>>website of patients
>>> > bitten by
>>> > >>>>>> Asian snakes and needing massive transfusions 
>>>after
>>> "unnecessary"
>>> > >>>>>> fasciotomy but they may be dealing with 
>>>different animals.
>>> > >>>>>>
>>> > >>>>>> Thanks,
>>> > >>>>>> Miranda Voss,
>>> > >>>>>> Worcester, South Africa.
>>> > >>>>>> --
>>> > >>>>>> trauma-list : TRAUMA.ORG
>>> > >>>>>> To change your settings or unsubscribe visit:
>>> > >>>>>> http://www.trauma.org/index.php?/co
>>> > >>> --
>>> > >>> Sent from Gmail Mobile
>>> > >>> --
>>> > >>> trauma-list : TRAUMA.ORG
>>> > >>> To change your settings or unsubscribe visit:
>>> > >>> http://www.trauma.org/index.php?/community/
>>> > >>
>>> > >> --
>>> > >> trauma-list : TRAUMA.ORG
>>> > >> To change your settings or unsubscribe visit:
>>> > >> http://www.trauma.org/index.php?/community/
>>> > >
>>> > > --
>>> > > Dr Ian Seppelt FANZCA FCICM
>>> > > Senior Specialist in Intensive Care Medicine
>>> > > Nepean Hospital, Penrith NSW
>>> > > Sydney Medical School - Nepean, University of Sydney
>>> > >
>>> > > --
>>> > > trauma-list : TRAUMA.ORG
>>> > > To change your settings or unsubscribe visit:
>>> > > http://www.trauma.org/index.php?/community/
>>> >
>>> > --
>>> > trauma-list : TRAUMA.ORG
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>>> > http://www.trauma.org/index.php?/community/
>>> > --
>>> > trauma-list : TRAUMA.ORG
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>>> >
>>> --
>>> trauma-list : TRAUMA.ORG
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>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
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>>
> 
> 
> Dr T C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Senior Lecturer UKZN Dept Surgery
> Deputy Director - IALCH Trauma Service
> Durban, South Africa
> 
> 
> 
> ------------------------------
> 
> Message: 3
> Date: Sun, 25 Mar 2012 16:42:31 +0200
>From: daniel simon <danielsimonster at gmail.com>
> Subject: Re: trauma-list Digest, Vol 105, Issue 11
> To: trauma-list at trauma.org
> Message-ID:
> 	<CAKuZ_YDkyirO0nHecX0zq4L_GNQ3YkLKcgwucqCZ8Xz-vP0e7w at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
> 
> On 3/23/12, trauma-list-request at trauma.org
> <trauma-list-request at trauma.org> wrote:
>> Send trauma-list mailing list submissions to
>> 	trauma-list at trauma.org
>>
>> To subscribe or unsubscribe via the World Wide Web, 
>>visit
>> 	http://list.mistral.net/mailman/listinfo/trauma-list
>> or, via email, send a message with subject or body 
>>'help' to
>> 	trauma-list-request at trauma.org
>>
>> You can reach the person managing the list at
>> 	trauma-list-owner at trauma.org
>>
>> When replying, please edit your Subject line so it is 
>>more specific
>> than "Re: Contents of trauma-list digest..."
>>
> 
> 
> ------------------------------
> 
> Message: 4
> Date: Sat, 31 Mar 2012 05:12:24 -1000
>From: Caesar Ursic <cmursic at gmail.com>
> Subject: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID:
> 	<CAG1MY2DvtueuDkgxvErvP67jUHc02Qr2GoknL6ZCmU6aZ7fHRQ at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
> 
>For those of you who work in designated/verified trauma 
>centers:
> 
> What is your official policy (or your opinion if there 
>is no actual policy
> where you are) on the transfer of trauma patients from 
>*your* ICU (at a
> trauma center) to another ICU at an outside hospital 
>that is *not* a trauma
> center?  Obviously I am speaking of transfers for 
>reasons *other* than
> provision of higher level of care, i.e. you are 
>transferring for
> non-medical reasons.  Perhaps the reason is that the 
>family wants the
> patient to be closer to home, or perhaps the patient 
>belongs to a hospital
> plan that, for financial reasons, prefers its patients 
>to be treated at
> specific participating institutions which are NOT 
>designated trauma centers.
> 
> Is it an acceptable risk to the patient to transfer 
>him/her ICU to ICU when
> there is no *medical* need to do so? Or should the 
>transfer wait until the
> patient is downgraded to "floor status," based on 
>improvement of medical
> condition and acuity?
> 
> Many thanks,
> 
> C. Ursic, MD
> 
> 
> ------------------------------
> 
> Message: 5
> Date: Sat, 31 Mar 2012 05:14:25 -1000
>From: Caesar Ursic <cmursic at gmail.com>
> Subject: Re: non slithering country
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID:
> 	<CAG1MY2C06BxC6Tn7=6jxAQNb+Q92t=Bot6eZJGkU5O7iEsASOA at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
> 
> Or Hawaii.
> No snakes in Hawaii.
> 
> 
> On Fri, Mar 23, 2012 at 9:38 PM, Marcin & Ania 
><Zawisza at xtra.co.nz> wrote:
> 
>> In answer to your question Brian- New Zealand is your 
>>best bet :-)
>>
>> Martin
>>
>>
>> Not to change the subject, but as someone who loves 
>>tropical and
>> semi-tropical weather but is absolutely TERRIFIED (i can 
>>BARELY stand being
>> in the reptile house at the zoo, i probably need 
>>professional help, huh?
>>  of snakes, is there anywhere on Earth I can get the 
>>great weather
>> combined with a lack of the slithering devils?
>> Bryan
>>
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.**php?/community/<http://www.trauma.org/index.php?/community/>
>>
> 
> 
> 
> -- 
> 'Twas brillig, and the slithy toves
> Did gyre and gimble in the wabe:
> All mimsy were the borogoves,
> And the mome raths outgrabe.
> 
> 
> ------------------------------
> 
> Message: 6
> Date: Sat, 31 Mar 2012 17:22:54 +0200 (SAST)
>From: "Dr Timothy Hardcastle" 
><dr.tchardcastle at absamail.co.za>
> Subject: Re: ICU to ICU transfers: what is your policy?
> To: "Trauma-List \[TRAUMA.ORG\]" 
><trauma-list at trauma.org>
> Message-ID:
> 	<15574.41.242.231.132.1333207374.squirrel at aiamail.lantic.net>
> Content-Type: text/plain;charset=iso-8859-1
> 
> Without a good medical reason for any ICU to ICU 
>transfer the answer is NO
> - we do not even allow transfers within the institution 
>between the
> various ICU's - and I'm talking about South Africa - a 
>developing country.
> In the USA with the MRSA etc risk it would be even less 
>wise - the level
> of care issue would not even be a consideration.
> 
> Tim
> South Africa
>> For those of you who work in designated/verified trauma 
>>centers:
>>
>> What is your official policy (or your opinion if there 
>>is no actual policy
>> where you are) on the transfer of trauma patients from 
>>*your* ICU (at a
>> trauma center) to another ICU at an outside hospital 
>>that is *not* a
>> trauma
>> center?  Obviously I am speaking of transfers for 
>>reasons *other* than
>> provision of higher level of care, i.e. you are 
>>transferring for
>> non-medical reasons.  Perhaps the reason is that the 
>>family wants the
>> patient to be closer to home, or perhaps the patient 
>>belongs to a hospital
>> plan that, for financial reasons, prefers its patients 
>>to be treated at
>> specific participating institutions which are NOT 
>>designated trauma
>> centers.
>>
>> Is it an acceptable risk to the patient to transfer 
>>him/her ICU to ICU
>> when
>> there is no *medical* need to do so? Or should the 
>>transfer wait until the
>> patient is downgraded to "floor status," based on 
>>improvement of medical
>> condition and acuity?
>>
>> Many thanks,
>>
>> C. Ursic, MD
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>>
> 
> 
> Dr T C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Senior Lecturer UKZN Dept Surgery
> Deputy Director - IALCH Trauma Service
> Durban, South Africa
> 
> 
> 
> ------------------------------
> 
> Message: 7
> Date: Sat, 31 Mar 2012 14:44:56 -0400
>From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
> Subject: Re: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID: 
><A36DDB09-44F5-435A-B53E-0D4F916F1961 at baystatehealth.org>
> Content-Type: text/plain; charset="us-ascii"
> 
> You cannot justify transferring a patient from a higher 
>level of care to a lesser level of care. You just can't. 
> On the other hand if the patient is on the floor and the 
>level of care is basic then I could see the convenience 
>transfer.....sometimes. 
> Ron
> 
> Sent from my iPhone
> 
> On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
><cmursic at gmail.com> wrote:
> 
>> For those of you who work in designated/verified trauma 
>>centers:
>> 
>> What is your official policy (or your opinion if there 
>>is no actual policy
>> where you are) on the transfer of trauma patients from 
>>*your* ICU (at a
>> trauma center) to another ICU at an outside hospital 
>>that is *not* a trauma
>> center?  Obviously I am speaking of transfers for 
>>reasons *other* than
>> provision of higher level of care, i.e. you are 
>>transferring for
>> non-medical reasons.  Perhaps the reason is that the 
>>family wants the
>> patient to be closer to home, or perhaps the patient 
>>belongs to a hospital
>> plan that, for financial reasons, prefers its patients 
>>to be treated at
>> specific participating institutions which are NOT 
>>designated trauma centers.
>> 
>> Is it an acceptable risk to the patient to transfer 
>>him/her ICU to ICU when
>> there is no *medical* need to do so? Or should the 
>>transfer wait until the
>> patient is downgraded to "floor status," based on 
>>improvement of medical
>> condition and acuity?
>> 
>> Many thanks,
>> 
>> C. Ursic, MD
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
> 
> ----------------------------------------------------------------------
> Please view our annual report at 
>http://baystatehealth.org/annualreport
> 
> 
> CONFIDENTIALITY NOTICE: This e-mail communication and 
>any attachments may contain confidential and privileged 
>information for the use of the designated recipients 
>named above. If you are not the intended recipient, you 
>are hereby notified that you have received this 
>communication in error and that any review, disclosure, 
>dissemination, distribution or copying of it or its 
>contents is prohibited. If you have received this 
>communication in error, please reply to the sender 
>immediately or by telephone at 413-794-0000 and destroy 
>all copies of this communication and any attachments. For 
>further information regarding Baystate Health's privacy 
>policy, please visit our Internet site at 
>http://baystatehealth.org.
> 
> 
> ------------------------------
> 
> Message: 8
> Date: Sat, 31 Mar 2012 12:05:08 -0700
>From: Robert Smith <rfsmithmd at comcast.net>
> Subject: Re: ICU to ICU transfers: what is your policy?
> To: "Trauma-List \[TRAUMA.ORG\]" 
><trauma-list at trauma.org>
> Message-ID: 
><F8CEB512-2235-4F27-B02E-5E2B051303E8 at comcast.net>
> Content-Type: text/plain;	charset=us-ascii
> 
> Ron,
> 
> The bottom line is the podcast.
> 
> You sound totally exhausted. I've heard trauma is a 
>young man's game. Is there any truth to that?
> 
> 
> 
> Thanks for thinking of us,
> 
> Rob
> 
> 
> 
> Robert Smith, MD, MPH
> Secretary War Dogs Making It HomeChair, Div Pre-hospital 
>Care and Prevention (ret)
> Department of Trauma John H.Stroger Jr. Hospital of Cook 
>County
> War Dogs - Making it home
> Tiny service dog heals Hampshire Marine - 
>DailyHerald.com
> http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-dogs-making-it-home
> 
> 
> 
> 
> 
> 
> On Mar 31, 2012, at 11:44 AM, Gross, Ronald wrote:
> 
>> You cannot justify transferring a patient from a higher 
>>level of care to a lesser level of care. You just can't. 
>> On the other hand if the patient is on the floor and the 
>>level of care is basic then I could see the convenience 
>>transfer.....sometimes. 
>> Ron
>> 
>> Sent from my iPhone
>> 
>> On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
>><cmursic at gmail.com> wrote:
>> 
>>> For those of you who work in designated/verified trauma 
>>>centers:
>>> 
>>> What is your official policy (or your opinion if there 
>>>is no actual policy
>>> where you are) on the transfer of trauma patients from 
>>>*your* ICU (at a
>>> trauma center) to another ICU at an outside hospital 
>>>that is *not* a trauma
>>> center?  Obviously I am speaking of transfers for 
>>>reasons *other* than
>>> provision of higher level of care, i.e. you are 
>>>transferring for
>>> non-medical reasons.  Perhaps the reason is that the 
>>>family wants the
>>> patient to be closer to home, or perhaps the patient 
>>>belongs to a hospital
>>> plan that, for financial reasons, prefers its patients 
>>>to be treated at
>>> specific participating institutions which are NOT 
>>>designated trauma centers.
>>> 
>>> Is it an acceptable risk to the patient to transfer 
>>>him/her ICU to ICU when
>>> there is no *medical* need to do so? Or should the 
>>>transfer wait until the
>>> patient is downgraded to "floor status," based on 
>>>improvement of medical
>>> condition and acuity?
>>> 
>>> Many thanks,
>>> 
>>> C. Ursic, MD
>>> --
>>> trauma-list : TRAUMA.ORG
>>> To change your settings or unsubscribe visit:
>>> http://www.trauma.org/index.php?/community/
>> 
>> ----------------------------------------------------------------------
>> Please view our annual report at 
>>http://baystatehealth.org/annualreport
>> 
>> 
>> CONFIDENTIALITY NOTICE: This e-mail communication and 
>>any attachments may contain confidential and privileged 
>>information for the use of the designated recipients 
>>named above. If you are not the intended recipient, you 
>>are hereby notified that you have received this 
>>communication in error and that any review, disclosure, 
>>dissemination, distribution or copying of it or its 
>>contents is prohibited. If you have received this 
>>communication in error, please reply to the sender 
>>immediately or by telephone at 413-794-0000 and destroy 
>>all copies of this communication and any attachments. For 
>>further information regarding Baystate Health's privacy 
>>policy, please visit our Internet site at 
>>http://baystatehealth.org.
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
> 
> 
> 
> ------------------------------
> 
> Message: 9
> Date: Sat, 31 Mar 2012 12:00:26 -1000
>From: Caesar Ursic <cmursic at gmail.com>
> Subject: Re: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID:
> 	<CAG1MY2AUzP07ce+oG5N8krNXXkQvVPgxJ=AkxBu13vLELsCFPg at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
> 
> Ron, at your hospital is there any sort of policy, 
>either informal or
> written, that states that you do not transfer your ICU 
>patients out to
> lesser level of care ICU (i.e. to an outside non trauma 
>center ICU)?
> 
> 
> 
> On Sun, Apr 1, 2012 at 9:05 AM, Robert Smith 
><rfsmithmd at comcast.net> wrote:
> 
>> Ron,
>>
>> The bottom line is the podcast.
>>
>> You sound totally exhausted. I've heard trauma is a 
>>young man's game. Is
>> there any truth to that?
>>
>>
>>
>> Thanks for thinking of us,
>>
>> Rob
>>
>>
>>
>> Robert Smith, MD, MPH
>> Secretary War Dogs Making It HomeChair, Div Pre-hospital 
>>Care and
>> Prevention (ret)
>> Department of Trauma John H.Stroger Jr. Hospital of Cook 
>>County
>> War Dogs - Making it home
>> Tiny service dog heals Hampshire Marine - 
>>DailyHerald.com
>>
>> http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-dogs-making-it-home
>>
>>
>>
>>
>>
>>
>> On Mar 31, 2012, at 11:44 AM, Gross, Ronald wrote:
>>
>> > You cannot justify transferring a patient from a 
>>higher level of care to
>> a lesser level of care. You just can't.  On the other 
>>hand if the patient
>> is on the floor and the level of care is basic then I 
>>could see the
>> convenience transfer.....sometimes.
>> > Ron
>> >
>> > Sent from my iPhone
>> >
>> > On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
>><cmursic at gmail.com> wrote:
>> >
>> >> For those of you who work in designated/verified 
>>trauma centers:
>> >>
>> >> What is your official policy (or your opinion if 
>>there is no actual
>> policy
>> >> where you are) on the transfer of trauma patients 
>>from *your* ICU (at a
>> >> trauma center) to another ICU at an outside hospital 
>>that is *not* a
>> trauma
>> >> center?  Obviously I am speaking of transfers for 
>>reasons *other* than
>> >> provision of higher level of care, i.e. you are 
>>transferring for
>> >> non-medical reasons.  Perhaps the reason is that the 
>>family wants the
>> >> patient to be closer to home, or perhaps the patient 
>>belongs to a
>> hospital
>> >> plan that, for financial reasons, prefers its 
>>patients to be treated at
>> >> specific participating institutions which are NOT 
>>designated trauma
>> centers.
>> >>
>> >> Is it an acceptable risk to the patient to transfer 
>>him/her ICU to ICU
>> when
>> >> there is no *medical* need to do so? Or should the 
>>transfer wait until
>> the
>> >> patient is downgraded to "floor status," based on 
>>improvement of medical
>> >> condition and acuity?
>> >>
>> >> Many thanks,
>> >>
>> >> C. Ursic, MD
>> >> --
>> >> trauma-list : TRAUMA.ORG
>> >> To change your settings or unsubscribe visit:
>> >> http://www.trauma.org/index.php?/community/
>> >
>> > 
>>----------------------------------------------------------------------
>> > Please view our annual report at 
>>http://baystatehealth.org/annualreport
>> >
>> >
>> > CONFIDENTIALITY NOTICE: This e-mail communication and 
>>any attachments
>> may contain confidential and privileged information for 
>>the use of the
>> designated recipients named above. If you are not the 
>>intended recipient,
>> you are hereby notified that you have received this 
>>communication in error
>> and that any review, disclosure, dissemination, 
>>distribution or copying of
>> it or its contents is prohibited. If you have received 
>>this communication
>> in error, please reply to the sender immediately or by 
>>telephone at
>> 413-794-0000 and destroy all copies of this 
>>communication and any
>> attachments. For further information regarding Baystate 
>>Health's privacy
>> policy, please visit our Internet site at 
>>http://baystatehealth.org.
>> > --
>> > trauma-list : TRAUMA.ORG
>> > To change your settings or unsubscribe visit:
>> > http://www.trauma.org/index.php?/community/
>>
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>>
> 
> 
> 
> -- 
> 'Twas brillig, and the slithy toves
> Did gyre and gimble in the wabe:
> All mimsy were the borogoves,
> And the mome raths outgrabe.
> 
> 
> ------------------------------
> 
> Message: 10
> Date: Sat, 31 Mar 2012 18:08:58 -0500
>From: "McSwain, Norman E" <nmcswai at tulane.edu>
> Subject: RE: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID:
> 	<2AB2A689A074DB439A79EF89F66CB97DD89555 at EX05.ad.tulane.edu>
> Content-Type: text/plain;	charset="us-ascii"
> 
> If you want to transfer down, it must go to the ICU 
>first and the
> receiving ICU can transfer to the floor
> 
> Norman
> 
> Norman McSwain MD, FACS
> Professor of Surgery, Tulane University
> Trauma director, Spirit of Charity Trauma Center, ILH
> 504 988 5111
> 
> 
> -----Original Message-----
>From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of 
>Caesar Ursic
> Sent: Saturday, March 31, 2012 5:00 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: ICU to ICU transfers: what is your policy?
> 
> Ron, at your hospital is there any sort of policy, 
>either informal or
> written, that states that you do not transfer your ICU 
>patients out to
> lesser level of care ICU (i.e. to an outside non trauma 
>center ICU)?
> 
> 
> 
> On Sun, Apr 1, 2012 at 9:05 AM, Robert Smith 
><rfsmithmd at comcast.net>
> wrote:
> 
>> Ron,
>>
>> The bottom line is the podcast.
>>
>> You sound totally exhausted. I've heard trauma is a 
>>young man's game. 
>> Is there any truth to that?
>>
>>
>>
>> Thanks for thinking of us,
>>
>> Rob
>>
>>
>>
>> Robert Smith, MD, MPH
>> Secretary War Dogs Making It HomeChair, Div Pre-hospital 
>>Care and 
>> Prevention (ret) Department of Trauma John H.Stroger Jr. 
>>Hospital of 
>> Cook County War Dogs - Making it home Tiny service dog 
>>heals Hampshire
> 
>> Marine - DailyHerald.com
>>
>> http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-do
>> gs-making-it-home
>>
>>
>>
>>
>>
>>
>> On Mar 31, 2012, at 11:44 AM, Gross, Ronald wrote:
>>
>> > You cannot justify transferring a patient from a 
>>higher level of 
>> > care to
>> a lesser level of care. You just can't.  On the other 
>>hand if the 
>> patient is on the floor and the level of care is basic 
>>then I could 
>> see the convenience transfer.....sometimes.
>> > Ron
>> >
>> > Sent from my iPhone
>> >
>> > On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
>><cmursic at gmail.com>
> wrote:
>> >
>> >> For those of you who work in designated/verified 
>>trauma centers:
>> >>
>> >> What is your official policy (or your opinion if 
>>there is no actual
>> policy
>> >> where you are) on the transfer of trauma patients 
>>from *your* ICU 
>> >> (at a trauma center) to another ICU at an outside 
>>hospital that is 
>> >> *not* a
>> trauma
>> >> center?  Obviously I am speaking of transfers for 
>>reasons *other* 
>> >> than provision of higher level of care, i.e. you are 
>>transferring 
>> >> for non-medical reasons.  Perhaps the reason is that 
>>the family 
>> >> wants the patient to be closer to home, or perhaps 
>>the patient 
>> >> belongs to a
>> hospital
>> >> plan that, for financial reasons, prefers its 
>>patients to be 
>> >> treated at specific participating institutions which 
>>are NOT 
>> >> designated trauma
>> centers.
>> >>
>> >> Is it an acceptable risk to the patient to transfer 
>>him/her ICU to 
>> >> ICU
>> when
>> >> there is no *medical* need to do so? Or should the 
>>transfer wait 
>> >> until
>> the
>> >> patient is downgraded to "floor status," based on 
>>improvement of 
>> >> medical condition and acuity?
>> >>
>> >> Many thanks,
>> >>
>> >> C. Ursic, MD
>> >> --
>> >> trauma-list : TRAUMA.ORG
>> >> To change your settings or unsubscribe visit:
>> >> http://www.trauma.org/index.php?/community/
>> >
>> > 
>>--------------------------------------------------------------------
>> > -- Please view our annual report at 
>> > http://baystatehealth.org/annualreport
>> >
>> >
>> > CONFIDENTIALITY NOTICE: This e-mail communication and 
>>any 
>> > attachments
>> may contain confidential and privileged information for 
>>the use of the
> 
>> designated recipients named above. If you are not the 
>>intended 
>> recipient, you are hereby notified that you have 
>>received this 
>> communication in error and that any review, disclosure, 
>>dissemination,
> 
>> distribution or copying of it or its contents is 
>>prohibited. If you 
>> have received this communication in error, please reply 
>>to the sender 
>> immediately or by telephone at
>> 413-794-0000 and destroy all copies of this 
>>communication and any 
>> attachments. For further information regarding Baystate 
>>Health's 
>> privacy policy, please visit our Internet site at
> http://baystatehealth.org.
>> > --
>> > trauma-list : TRAUMA.ORG
>> > To change your settings or unsubscribe visit:
>> > http://www.trauma.org/index.php?/community/
>>
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>>
> 
> 
> 
> --
> 'Twas brillig, and the slithy toves
> Did gyre and gimble in the wabe:
> All mimsy were the borogoves,
> And the mome raths outgrabe.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 
> 
> ------------------------------
> 
> Message: 11
> Date: Sat, 31 Mar 2012 18:07:51 -0500
>From: "McSwain, Norman E" <nmcswai at tulane.edu>
> Subject: RE: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID:
> 	<2AB2A689A074DB439A79EF89F66CB97DD89554 at EX05.ad.tulane.edu>
> Content-Type: text/plain;	charset="us-ascii"
> 
> CMS and EMTALA have rules that you cannot transfer to a 
>lesser level of
> care
> 
> Norman
> 
> Norman McSwain MD, FACS
> Professor of Surgery, Tulane University
> Trauma director, Spirit of Charity Trauma Center, ILH
> 504 988 5111
> 
> 
> -----Original Message-----
>From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of 
>Caesar Ursic
> Sent: Saturday, March 31, 2012 5:00 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: ICU to ICU transfers: what is your policy?
> 
> Ron, at your hospital is there any sort of policy, 
>either informal or
> written, that states that you do not transfer your ICU 
>patients out to
> lesser level of care ICU (i.e. to an outside non trauma 
>center ICU)?
> 
> 
> 
> On Sun, Apr 1, 2012 at 9:05 AM, Robert Smith 
><rfsmithmd at comcast.net>
> wrote:
> 
>> Ron,
>>
>> The bottom line is the podcast.
>>
>> You sound totally exhausted. I've heard trauma is a 
>>young man's game. 
>> Is there any truth to that?
>>
>>
>>
>> Thanks for thinking of us,
>>
>> Rob
>>
>>
>>
>> Robert Smith, MD, MPH
>> Secretary War Dogs Making It HomeChair, Div Pre-hospital 
>>Care and 
>> Prevention (ret) Department of Trauma John H.Stroger Jr. 
>>Hospital of 
>> Cook County War Dogs - Making it home Tiny service dog 
>>heals Hampshire
> 
>> Marine - DailyHerald.com
>>
>> http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-do
>> gs-making-it-home
>>
>>
>>
>>
>>
>>
>> On Mar 31, 2012, at 11:44 AM, Gross, Ronald wrote:
>>
>> > You cannot justify transferring a patient from a 
>>higher level of 
>> > care to
>> a lesser level of care. You just can't.  On the other 
>>hand if the 
>> patient is on the floor and the level of care is basic 
>>then I could 
>> see the convenience transfer.....sometimes.
>> > Ron
>> >
>> > Sent from my iPhone
>> >
>> > On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
>><cmursic at gmail.com>
> wrote:
>> >
>> >> For those of you who work in designated/verified 
>>trauma centers:
>> >>
>> >> What is your official policy (or your opinion if 
>>there is no actual
>> policy
>> >> where you are) on the transfer of trauma patients 
>>from *your* ICU 
>> >> (at a trauma center) to another ICU at an outside 
>>hospital that is 
>> >> *not* a
>> trauma
>> >> center?  Obviously I am speaking of transfers for 
>>reasons *other* 
>> >> than provision of higher level of care, i.e. you are 
>>transferring 
>> >> for non-medical reasons.  Perhaps the reason is that 
>>the family 
>> >> wants the patient to be closer to home, or perhaps 
>>the patient 
>> >> belongs to a
>> hospital
>> >> plan that, for financial reasons, prefers its 
>>patients to be 
>> >> treated at specific participating institutions which 
>>are NOT 
>> >> designated trauma
>> centers.
>> >>
>> >> Is it an acceptable risk to the patient to transfer 
>>him/her ICU to 
>> >> ICU
>> when
>> >> there is no *medical* need to do so? Or should the 
>>transfer wait 
>> >> until
>> the
>> >> patient is downgraded to "floor status," based on 
>>improvement of 
>> >> medical condition and acuity?
>> >>
>> >> Many thanks,
>> >>
>> >> C. Ursic, MD
>> >> --
>> >> trauma-list : TRAUMA.ORG
>> >> To change your settings or unsubscribe visit:
>> >> http://www.trauma.org/index.php?/community/
>> >
>> > 
>>--------------------------------------------------------------------
>> > -- Please view our annual report at 
>> > http://baystatehealth.org/annualreport
>> >
>> >
>> > CONFIDENTIALITY NOTICE: This e-mail communication and 
>>any 
>> > attachments
>> may contain confidential and privileged information for 
>>the use of the
> 
>> designated recipients named above. If you are not the 
>>intended 
>> recipient, you are hereby notified that you have 
>>received this 
>> communication in error and that any review, disclosure, 
>>dissemination,
> 
>> distribution or copying of it or its contents is 
>>prohibited. If you 
>> have received this communication in error, please reply 
>>to the sender 
>> immediately or by telephone at
>> 413-794-0000 and destroy all copies of this 
>>communication and any 
>> attachments. For further information regarding Baystate 
>>Health's 
>> privacy policy, please visit our Internet site at
> http://baystatehealth.org.
>> > --
>> > trauma-list : TRAUMA.ORG
>> > To change your settings or unsubscribe visit:
>> > http://www.trauma.org/index.php?/community/
>>
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>>
> 
> 
> 
> --
> 'Twas brillig, and the slithy toves
> Did gyre and gimble in the wabe:
> All mimsy were the borogoves,
> And the mome raths outgrabe.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 
> 
> ------------------------------
> 
> Message: 12
> Date: Sat, 31 Mar 2012 18:13:45 -0500
>From: K Mattox <kmattox at aol.com>
> Subject: Re: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Cc: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID: 
><A2940479-DFE8-4B4A-A54D-0E95B42F7D44 at aol.com>
> Content-Type: text/plain;	charset=us-ascii
> 
> This has nothing to do with what a "plan  wants.".   It 
>has to do with the receiving doctor to provide a quality 
>of care equal to that being currently rendered.  
> 
> k
> 
> Sent from my iPhone
> 
> On Mar 31, 2012, at 5:00 PM, Caesar Ursic 
><cmursic at gmail.com> wrote:
> 
>> Ron, at your hospital is there any sort of policy, 
>>either informal or
>> written, that states that you do not transfer your ICU 
>>patients out to
>> lesser level of care ICU (i.e. to an outside non trauma 
>>center ICU)?
>> 
>> 
>> 
>> On Sun, Apr 1, 2012 at 9:05 AM, Robert Smith 
>><rfsmithmd at comcast.net> wrote:
>> 
>>> Ron,
>>> 
>>> The bottom line is the podcast.
>>> 
>>> You sound totally exhausted. I've heard trauma is a 
>>>young man's game. Is
>>> there any truth to that?
>>> 
>>> 
>>> 
>>> Thanks for thinking of us,
>>> 
>>> Rob
>>> 
>>> 
>>> 
>>> Robert Smith, MD, MPH
>>> Secretary War Dogs Making It HomeChair, Div Pre-hospital 
>>>Care and
>>> Prevention (ret)
>>> Department of Trauma John H.Stroger Jr. Hospital of Cook 
>>>County
>>> War Dogs - Making it home
>>> Tiny service dog heals Hampshire Marine - 
>>>DailyHerald.com
>>> 
>>> http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-dogs-making-it-home
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> On Mar 31, 2012, at 11:44 AM, Gross, Ronald wrote:
>>> 
>>>> You cannot justify transferring a patient from a higher 
>>>>level of care to
>>> a lesser level of care. You just can't.  On the other 
>>>hand if the patient
>>> is on the floor and the level of care is basic then I 
>>>could see the
>>> convenience transfer.....sometimes.
>>>> Ron
>>>> 
>>>> Sent from my iPhone
>>>> 
>>>> On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
>>>><cmursic at gmail.com> wrote:
>>>> 
>>>>> For those of you who work in designated/verified trauma 
>>>>>centers:
>>>>> 
>>>>> What is your official policy (or your opinion if there 
>>>>>is no actual
>>> policy
>>>>> where you are) on the transfer of trauma patients from 
>>>>>*your* ICU (at a
>>>>> trauma center) to another ICU at an outside hospital 
>>>>>that is *not* a
>>> trauma
>>>>> center?  Obviously I am speaking of transfers for 
>>>>>reasons *other* than
>>>>> provision of higher level of care, i.e. you are 
>>>>>transferring for
>>>>> non-medical reasons.  Perhaps the reason is that the 
>>>>>family wants the
>>>>> patient to be closer to home, or perhaps the patient 
>>>>>belongs to a
>>> hospital
>>>>> plan that, for financial reasons, prefers its patients 
>>>>>to be treated at
>>>>> specific participating institutions which are NOT 
>>>>>designated trauma
>>> centers.
>>>>> 
>>>>> Is it an acceptable risk to the patient to transfer 
>>>>>him/her ICU to ICU
>>> when
>>>>> there is no *medical* need to do so? Or should the 
>>>>>transfer wait until
>>> the
>>>>> patient is downgraded to "floor status," based on 
>>>>>improvement of medical
>>>>> condition and acuity?
>>>>> 
>>>>> Many thanks,
>>>>> 
>>>>> C. Ursic, MD
>>>>> --
>>>>> trauma-list : TRAUMA.ORG
>>>>> To change your settings or unsubscribe visit:
>>>>> http://www.trauma.org/index.php?/community/
>>>> 
>>>> ----------------------------------------------------------------------
>>>> Please view our annual report at 
>>>>http://baystatehealth.org/annualreport
>>>> 
>>>> 
>>>> CONFIDENTIALITY NOTICE: This e-mail communication and 
>>>>any attachments
>>> may contain confidential and privileged information for 
>>>the use of the
>>> designated recipients named above. If you are not the 
>>>intended recipient,
>>> you are hereby notified that you have received this 
>>>communication in error
>>> and that any review, disclosure, dissemination, 
>>>distribution or copying of
>>> it or its contents is prohibited. If you have received 
>>>this communication
>>> in error, please reply to the sender immediately or by 
>>>telephone at
>>> 413-794-0000 and destroy all copies of this 
>>>communication and any
>>> attachments. For further information regarding Baystate 
>>>Health's privacy
>>> policy, please visit our Internet site at 
>>>http://baystatehealth.org.
>>>> --
>>>> trauma-list : TRAUMA.ORG
>>>> To change your settings or unsubscribe visit:
>>>> http://www.trauma.org/index.php?/community/
>>> 
>>> --
>>> trauma-list : TRAUMA.ORG
>>> To change your settings or unsubscribe visit:
>>> http://www.trauma.org/index.php?/community/
>>> 
>> 
>> 
>> 
>> -- 
>> 'Twas brillig, and the slithy toves
>> Did gyre and gimble in the wabe:
>> All mimsy were the borogoves,
>> And the mome raths outgrabe.
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
> 
> 
> ------------------------------
> 
> Message: 13
> Date: Sat, 31 Mar 2012 18:16:48 -0500
>From: K Mattox <kmattox at aol.com>
> Subject: Re: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Cc: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID: 
><7E76C3A7-81C4-4C63-B780-81F386ABD21B at aol.com>
> Content-Type: text/plain;	charset=us-ascii
> 
> Entails only applies to transfer from EC.     
> 
> k
> 
> Sent from my iPhone
> 
> On Mar 31, 2012, at 6:07 PM, "McSwain, Norman E" 
><nmcswai at tulane.edu> wrote:
> 
>> CMS and EMTALA have rules that you cannot transfer to a 
>>lesser level of
>> care
>> 
>> Norman
>> 
>> Norman McSwain MD, FACS
>> Professor of Surgery, Tulane University
>> Trauma director, Spirit of Charity Trauma Center, ILH
>> 504 988 5111
>> 
>> 
>> -----Original Message-----
>> From: trauma-list-bounces at trauma.org
>> [mailto:trauma-list-bounces at trauma.org] On Behalf Of 
>>Caesar Ursic
>> Sent: Saturday, March 31, 2012 5:00 PM
>> To: Trauma-List [TRAUMA.ORG]
>> Subject: Re: ICU to ICU transfers: what is your policy?
>> 
>> Ron, at your hospital is there any sort of policy, 
>>either informal or
>> written, that states that you do not transfer your ICU 
>>patients out to
>> lesser level of care ICU (i.e. to an outside non trauma 
>>center ICU)?
>> 
>> 
>> 
>> On Sun, Apr 1, 2012 at 9:05 AM, Robert Smith 
>><rfsmithmd at comcast.net>
>> wrote:
>> 
>>> Ron,
>>> 
>>> The bottom line is the podcast.
>>> 
>>> You sound totally exhausted. I've heard trauma is a 
>>>young man's game. 
>>> Is there any truth to that?
>>> 
>>> 
>>> 
>>> Thanks for thinking of us,
>>> 
>>> Rob
>>> 
>>> 
>>> 
>>> Robert Smith, MD, MPH
>>> Secretary War Dogs Making It HomeChair, Div Pre-hospital 
>>>Care and 
>>> Prevention (ret) Department of Trauma John H.Stroger Jr. 
>>>Hospital of 
>>> Cook County War Dogs - Making it home Tiny service dog 
>>>heals Hampshire
>> 
>>> Marine - DailyHerald.com
>>> 
>>> http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-do
>>> gs-making-it-home
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> On Mar 31, 2012, at 11:44 AM, Gross, Ronald wrote:
>>> 
>>>> You cannot justify transferring a patient from a higher 
>>>>level of 
>>>> care to
>>> a lesser level of care. You just can't.  On the other 
>>>hand if the 
>>> patient is on the floor and the level of care is basic 
>>>then I could 
>>> see the convenience transfer.....sometimes.
>>>> Ron
>>>> 
>>>> Sent from my iPhone
>>>> 
>>>> On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
>>>><cmursic at gmail.com>
>> wrote:
>>>> 
>>>>> For those of you who work in designated/verified trauma 
>>>>>centers:
>>>>> 
>>>>> What is your official policy (or your opinion if there 
>>>>>is no actual
>>> policy
>>>>> where you are) on the transfer of trauma patients from 
>>>>>*your* ICU 
>>>>> (at a trauma center) to another ICU at an outside 
>>>>>hospital that is 
>>>>> *not* a
>>> trauma
>>>>> center?  Obviously I am speaking of transfers for 
>>>>>reasons *other* 
>>>>> than provision of higher level of care, i.e. you are 
>>>>>transferring 
>>>>> for non-medical reasons.  Perhaps the reason is that the 
>>>>>family 
>>>>> wants the patient to be closer to home, or perhaps the 
>>>>>patient 
>>>>> belongs to a
>>> hospital
>>>>> plan that, for financial reasons, prefers its patients 
>>>>>to be 
>>>>> treated at specific participating institutions which are 
>>>>>NOT 
>>>>> designated trauma
>>> centers.
>>>>> 
>>>>> Is it an acceptable risk to the patient to transfer 
>>>>>him/her ICU to 
>>>>> ICU
>>> when
>>>>> there is no *medical* need to do so? Or should the 
>>>>>transfer wait 
>>>>> until
>>> the
>>>>> patient is downgraded to "floor status," based on 
>>>>>improvement of 
>>>>> medical condition and acuity?
>>>>> 
>>>>> Many thanks,
>>>>> 
>>>>> C. Ursic, MD
>>>>> --
>>>>> trauma-list : TRAUMA.ORG
>>>>> To change your settings or unsubscribe visit:
>>>>> http://www.trauma.org/index.php?/community/
>>>> 
>>>> --------------------------------------------------------------------
>>>> -- Please view our annual report at 
>>>> http://baystatehealth.org/annualreport
>>>> 
>>>> 
>>>> CONFIDENTIALITY NOTICE: This e-mail communication and 
>>>>any 
>>>> attachments
>>> may contain confidential and privileged information for 
>>>the use of the
>> 
>>> designated recipients named above. If you are not the 
>>>intended 
>>> recipient, you are hereby notified that you have 
>>>received this 
>>> communication in error and that any review, disclosure, 
>>>dissemination,
>> 
>>> distribution or copying of it or its contents is 
>>>prohibited. If you 
>>> have received this communication in error, please reply 
>>>to the sender 
>>> immediately or by telephone at
>>> 413-794-0000 and destroy all copies of this 
>>>communication and any 
>>> attachments. For further information regarding Baystate 
>>>Health's 
>>> privacy policy, please visit our Internet site at
>> http://baystatehealth.org.
>>>> --
>>>> trauma-list : TRAUMA.ORG
>>>> To change your settings or unsubscribe visit:
>>>> http://www.trauma.org/index.php?/community/
>>> 
>>> --
>>> trauma-list : TRAUMA.ORG
>>> To change your settings or unsubscribe visit:
>>> http://www.trauma.org/index.php?/community/
>>> 
>> 
>> 
>> 
>> --
>> 'Twas brillig, and the slithy toves
>> Did gyre and gimble in the wabe:
>> All mimsy were the borogoves,
>> And the mome raths outgrabe.
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
> 
> 
> ------------------------------
> 
> Message: 14
> Date: Sun, 1 Apr 2012 12:44:46 -0400
>From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
> Subject: Re: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Cc: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID: 
><8DFC535A-B9E2-4F47-B684-33463A3DCB0D at baystatehealth.org>
> Content-Type: text/plain; charset="us-ascii"
> 
> Caesar,
> In fact there is - and it is written as such in part 
>because the COT and, more importantly (if you can imagine 
>that) insurers mandate it. 
> Ron
> 
> Sent from my iPhone
> 
> On Mar 31, 2012, at 6:00 PM, "Caesar Ursic" 
><cmursic at gmail.com> wrote:
> 
>> Ron, at your hospital is there any sort of policy, 
>>either informal or
>> written, that states that you do not transfer your ICU 
>>patients out to
>> lesser level of care ICU (i.e. to an outside non trauma 
>>center ICU)?
>> 
>> 
>> 
>> On Sun, Apr 1, 2012 at 9:05 AM, Robert Smith 
>><rfsmithmd at comcast.net> wrote:
>> 
>>> Ron,
>>> 
>>> The bottom line is the podcast.
>>> 
>>> You sound totally exhausted. I've heard trauma is a 
>>>young man's game. Is
>>> there any truth to that?
>>> 
>>> 
>>> 
>>> Thanks for thinking of us,
>>> 
>>> Rob
>>> 
>>> 
>>> 
>>> Robert Smith, MD, MPH
>>> Secretary War Dogs Making It HomeChair, Div Pre-hospital 
>>>Care and
>>> Prevention (ret)
>>> Department of Trauma John H.Stroger Jr. Hospital of Cook 
>>>County
>>> War Dogs - Making it home
>>> Tiny service dog heals Hampshire Marine - 
>>>DailyHerald.com
>>> 
>>> http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-dogs-making-it-home
>>> 
>>> 
>>> 
>>> 
>>> 
>>> 
>>> On Mar 31, 2012, at 11:44 AM, Gross, Ronald wrote:
>>> 
>>>> You cannot justify transferring a patient from a higher 
>>>>level of care to
>>> a lesser level of care. You just can't.  On the other 
>>>hand if the patient
>>> is on the floor and the level of care is basic then I 
>>>could see the
>>> convenience transfer.....sometimes.
>>>> Ron
>>>> 
>>>> Sent from my iPhone
>>>> 
>>>> On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
>>>><cmursic at gmail.com> wrote:
>>>> 
>>>>> For those of you who work in designated/verified trauma 
>>>>>centers:
>>>>> 
>>>>> What is your official policy (or your opinion if there 
>>>>>is no actual
>>> policy
>>>>> where you are) on the transfer of trauma patients from 
>>>>>*your* ICU (at a
>>>>> trauma center) to another ICU at an outside hospital 
>>>>>that is *not* a
>>> trauma
>>>>> center?  Obviously I am speaking of transfers for 
>>>>>reasons *other* than
>>>>> provision of higher level of care, i.e. you are 
>>>>>transferring for
>>>>> non-medical reasons.  Perhaps the reason is that the 
>>>>>family wants the
>>>>> patient to be closer to home, or perhaps the patient 
>>>>>belongs to a
>>> hospital
>>>>> plan that, for financial reasons, prefers its patients 
>>>>>to be treated at
>>>>> specific participating institutions which are NOT 
>>>>>designated trauma
>>> centers.
>>>>> 
>>>>> Is it an acceptable risk to the patient to transfer 
>>>>>him/her ICU to ICU
>>> when
>>>>> there is no *medical* need to do so? Or should the 
>>>>>transfer wait until
>>> the
>>>>> patient is downgraded to "floor status," based on 
>>>>>improvement of medical
>>>>> condition and acuity?
>>>>> 
>>>>> Many thanks,
>>>>> 
>>>>> C. Ursic, MD
>>>>> --
>>>>> trauma-list : TRAUMA.ORG
>>>>> To change your settings or unsubscribe visit:
>>>>> http://www.trauma.org/index.php?/community/
>>>> 
>>>> ----------------------------------------------------------------------
>>>> Please view our annual report at 
>>>>http://baystatehealth.org/annualreport
>>>> 
>>>> 
>>>> CONFIDENTIALITY NOTICE: This e-mail communication and 
>>>>any attachments
>>> may contain confidential and privileged information for 
>>>the use of the
>>> designated recipients named above. If you are not the 
>>>intended recipient,
>>> you are hereby notified that you have received this 
>>>communication in error
>>> and that any review, disclosure, dissemination, 
>>>distribution or copying of
>>> it or its contents is prohibited. If you have received 
>>>this communication
>>> in error, please reply to the sender immediately or by 
>>>telephone at
>>> 413-794-0000 and destroy all copies of this 
>>>communication and any
>>> attachments. For further information regarding Baystate 
>>>Health's privacy
>>> policy, please visit our Internet site at 
>>>http://baystatehealth.org.
>>>> --
>>>> trauma-list : TRAUMA.ORG
>>>> To change your settings or unsubscribe visit:
>>>> http://www.trauma.org/index.php?/community/
>>> 
>>> --
>>> trauma-list : TRAUMA.ORG
>>> To change your settings or unsubscribe visit:
>>> http://www.trauma.org/index.php?/community/
>>> 
>> 
>> 
>> 
>> -- 
>> 'Twas brillig, and the slithy toves
>> Did gyre and gimble in the wabe:
>> All mimsy were the borogoves,
>> And the mome raths outgrabe.
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
> 
> ----------------------------------------------------------------------
> Please view our annual report at 
>http://baystatehealth.org/annualreport
> 
> 
> CONFIDENTIALITY NOTICE: This e-mail communication and 
>any attachments may contain confidential and privileged 
>information for the use of the designated recipients 
>named above. If you are not the intended recipient, you 
>are hereby notified that you have received this 
>communication in error and that any review, disclosure, 
>dissemination, distribution or copying of it or its 
>contents is prohibited. If you have received this 
>communication in error, please reply to the sender 
>immediately or by telephone at 413-794-0000 and destroy 
>all copies of this communication and any attachments. For 
>further information regarding Baystate Health's privacy 
>policy, please visit our Internet site at 
>http://baystatehealth.org.
> 
> 
> ------------------------------
> 
> Message: 15
> Date: Sun, 1 Apr 2012 08:30:26 -1000
>From: Caesar Ursic <cmursic at gmail.com>
> Subject: Re: ICU to ICU transfers: what is your policy?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID:
> 	<CAG1MY2CpHg8_hCHi193fyrPdabYUVeEOf-PdawUpixtkLCtYXA at mail.gmail.com>
> Content-Type: text/plain; charset=ISO-8859-1
> 
> Thanks for all of the comments.
> 
> I am *not* referring to transfer to a lower level of 
>care in the sense that
> a patient is in ICU and you want to transfer to floor 
>bed somewhere else.
> Rather, I am referring to an *ICU to ICU transfer*, when 
>the sending ICU is
> in a trauma center and the receiving ICU is in a non- 
>trauma center.
> 
> How do you all feel about that?
> 
> Personally, I think those types of transfers should be 
>very seldom and
> rare, and certainly not based on economics.
> 
> 
> 
> 
> On Sun, Apr 1, 2012 at 6:44 AM, Gross, Ronald <
> Ronald.Gross at baystatehealth.org> wrote:
> 
>> Caesar,
>> In fact there is - and it is written as such in part 
>>because the COT and,
>> more importantly (if you can imagine that) insurers 
>>mandate it.
>> Ron
>>
>> Sent from my iPhone
>>
>> On Mar 31, 2012, at 6:00 PM, "Caesar Ursic" 
>><cmursic at gmail.com> wrote:
>>
>>  > Ron, at your hospital is there any sort of policy, 
>>either informal or
>> > written, that states that you do not transfer your ICU 
>>patients out to
>> > lesser level of care ICU (i.e. to an outside non 
>>trauma center ICU)?
>> >
>> >
>> >
>> > On Sun, Apr 1, 2012 at 9:05 AM, Robert Smith 
>><rfsmithmd at comcast.net>
>> wrote:
>> >
>> >> Ron,
>> >>
>> >> The bottom line is the podcast.
>> >>
>> >> You sound totally exhausted. I've heard trauma is a 
>>young man's game. Is
>> >> there any truth to that?
>> >>
>> >>
>> >>
>> >> Thanks for thinking of us,
>> >>
>> >> Rob
>> >>
>> >>
>> >>
>> >> Robert Smith, MD, MPH
>> >> Secretary War Dogs Making It HomeChair, Div 
>>Pre-hospital Care and
>> >> Prevention (ret)
>> >> Department of Trauma John H.Stroger Jr. Hospital of 
>>Cook County
>> >> War Dogs - Making it home
>> >> Tiny service dog heals Hampshire Marine - 
>>DailyHerald.com
>> >>
>> >>
>> http://www.whereistheoutrage.net/wordpress/2012/03/20/interview-war-dogs-making-it-home
>> >>
>> >>
>> >>
>> >>
>> >>
>> >>
>> >> On Mar 31, 2012, at 11:44 AM, Gross, Ronald wrote:
>> >>
>> >>> You cannot justify transferring a patient from a 
>>higher level of care
>> to
>> >> a lesser level of care. You just can't.  On the other 
>>hand if the
>> patient
>> >> is on the floor and the level of care is basic then I 
>>could see the
>> >> convenience transfer.....sometimes.
>> >>> Ron
>> >>>
>> >>> Sent from my iPhone
>> >>>
>> >>> On Mar 31, 2012, at 11:12 AM, "Caesar Ursic" 
>><cmursic at gmail.com>
>> wrote:
>> >>>
>> >>>> For those of you who work in designated/verified 
>>trauma centers:
>> >>>>
>> >>>> What is your official policy (or your opinion if 
>>there is no actual
>> >> policy
>> >>>> where you are) on the transfer of trauma patients 
>>from *your* ICU (at
>> a
>> >>>> trauma center) to another ICU at an outside 
>>hospital that is *not* a
>> >> trauma
>> >>>> center?  Obviously I am speaking of transfers for 
>>reasons *other* than
>> >>>> provision of higher level of care, i.e. you are 
>>transferring for
>> >>>> non-medical reasons.  Perhaps the reason is that 
>>the family wants the
>> >>>> patient to be closer to home, or perhaps the 
>>patient belongs to a
>> >> hospital
>> >>>> plan that, for financial reasons, prefers its 
>>patients to be treated
>> at
>> >>>> specific participating institutions which are NOT 
>>designated trauma
>> >> centers.
>> >>>>
>> >>>> Is it an acceptable risk to the patient to transfer 
>>him/her ICU to ICU
>> >> when
>> >>>> there is no *medical* need to do so? Or should the 
>>transfer wait until
>> >> the
>> >>>> patient is downgraded to "floor status," based on 
>>improvement of
>> medical
>> >>>> condition and acuity?
>> >>>>
>> >>>> Many thanks,
>> >>>>
>> >>>> C. Ursic, MD
>> >>>> --
>> >>>> trauma-list : TRAUMA.ORG <http://trauma.org/>
>> >>>> To change your settings or unsubscribe visit:
>> >>>> http://www.trauma.org/index.php?/community/
>> >>>
>> >>> 
>>----------------------------------------------------------------------
>> >>> Please view our annual report at
>> http://baystatehealth.org/annualreport
>> >>>
>> >>>
>> >>> CONFIDENTIALITY NOTICE: This e-mail communication 
>>and any attachments
>> >> may contain confidential and privileged information 
>>for the use of the
>> >> designated recipients named above. If you are not the 
>>intended
>> recipient,
>> >> you are hereby notified that you have received this 
>>communication in
>> error
>> >> and that any review, disclosure, dissemination, 
>>distribution or copying
>> of
>> >> it or its contents is prohibited. If you have 
>>received this
>> communication
>> >> in error, please reply to the sender immediately or 
>>by telephone at
>> >> 413-794-0000 and destroy all copies of this 
>>communication and any
>> >> attachments. For further information regarding 
>>Baystate Health's privacy
>> >> policy, please visit our Internet site at 
>>http://baystatehealth.org.
>> >>> --
>> >>> trauma-list : TRAUMA.ORG <http://trauma.org/>
>> >>> To change your settings or unsubscribe visit:
>> >>> http://www.trauma.org/index.php?/community/
>> >>
>> >> --
>> >> trauma-list : TRAUMA.ORG <http://trauma.org/>
>> >> To change your settings or unsubscribe visit:
>> >> http://www.trauma.org/index.php?/community/
>> >>
>> >
>> >
>> >
>> > --
>> > 'Twas brillig, and the slithy toves
>> > Did gyre and gimble in the wabe:
>> > All mimsy were the borogoves,
>> > And the mome raths outgrabe.
>> > --
>> > trauma-list : TRAUMA.ORG <http://trauma.org/>
>> > To change your settings or unsubscribe visit:
>> > http://www.trauma.org/index.php?/community/
>>
>> ----------------------------------------------------------------------
>> Please view our annual report at 
>>http://baystatehealth.org/annualreport
>>
>>
>> CONFIDENTIALITY NOTICE: This e-mail communication and 
>>any attachments may
>> contain confidential and privileged information for the 
>>use of the
>> designated recipients named above. If you are not the 
>>intended recipient,
>> you are hereby notified that you have received this 
>>communication in error
>> and that any review, disclosure, dissemination, 
>>distribution or copying of
>> it or its contents is prohibited. If you have received 
>>this communication
>> in error, please reply to the sender immediately or by 
>>telephone at
>> 413-794-0000 and destroy all copies of this 
>>communication and any
>> attachments. For further information regarding Baystate 
>>Health's privacy
>> policy, please visit our Internet site at 
>>http://baystatehealth.org.
>> --
>> trauma-list : TRAUMA.ORG <http://trauma.org/>
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>>
> 
> 
> 
> -- 
> 'Twas brillig, and the slithy toves
> Did gyre and gimble in the wabe:
> All mimsy were the borogoves,
> And the mome raths outgrabe.
> 
> 
> ------------------------------
> 
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> 
> End of trauma-list Digest, Vol 106, Issue 1
> *******************************************


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